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SMJ-59-150.Pdf Singapore Med J 2018; 59(3): 150-154 Original Article https://doi.org/10.11622/smedj.2017074 Management of computed tomography-detected pneumothorax in patients with blunt trauma: experience from a community-based hospital Ashraf F Hefny1,2, MD, Fathima T Kunhivalappil3, MD, Nikolay Matev3, MD, Norman A Avila4, BSN, Masoud O Bashir1, MD, Fikri M Abu-Zidan2, MD, PhD INTRODUCTION Diagnoses of pneumothorax, especially occult pneumothorax, have increased as the use of computed tomography (CT) for imaging trauma patients becomes near-routine. However, the need for chest tube insertion remains controversial. We aimed to study the management of pneumothorax detected on CT among patients with blunt trauma, including the decision for tube thoracostomy, in a community-based hospital. METHODS Chest CT scans of patients with blunt trauma treated at Al Rahba Hospital, Abu Dhabi, United Arab Emirates, from October 2010 to October 2014 were retrospectively studied. Variables studied included demography, mechanism of injury, endotracheal intubation, pneumothorax volume, chest tube insertion, Injury Severity Score, hospital length of stay and mortality. RESULTS CT was performed in 703 patients with blunt trauma. Overall, pneumothorax was detected on CT for 74 (10.5%) patients. Among the 65 patients for whom pneumothorax was detected before chest tube insertion, 25 (38.5%) needed chest tube insertion, while 40 (61.5%) did not. Backward stepwise likelihood regression showed that independent factors that significantly predicted chest tube insertion were endotracheal intubation (p = 0.01), non-United Arab Emirates nationality (p = 0.01) and pneumothorax volume (p = 0.03). The receiver operating characteristic curve showed that the best pneumothorax volume that predicted chest tube insertion was 30 mL. CONCLUSION Chest tube was inserted in less than half of the patients with blunt trauma for whom pneumothorax was detected on CT. Pneumothorax volume should be considered in decision-making regarding chest tube insertion. Conservative treatment may be sufficient for pneumothorax of volume < 30 mL. Keywords: computed tomography, pneumothorax, trauma INTRODUCTION ventilation should be administered in the patient who has In an era of rapid advances in imaging technology and resource sustained a traumatic pneumothorax until a chest tube has been constraints, more studies are needed to define the role of chest inserted”.(7) In contrast, a prospective multicentre randomised computed tomography (CT) for patients with multiple blunt controlled trial showed that in a haemodynamically stable patient, trauma. Advances in CT have greatly increased its diagnostic occult pneumothorax can be safely managed conservatively accuracy for acutely traumatised patients.(1) Recent studies have without chest tube insertion, even for mechanically ventilated demonstrated the value of chest CT for detecting chest injuries patients.(1) We aimed to study the management of CT-detected in spite of radiation exposure and cost.(2) Thoracic injury is a pneumothorax in patients with blunt trauma, including the major cause of trauma-related death.(3) Routine use of chest CT decision to insert a chest tube, in a community-based hospital for patients with multiple trauma is preferable to selective use, as setting. it could change the course of patient management and improve outcomes.(4) METHODS Pneumothorax is the most common, potentially life- All chest CT images of patients with blunt trauma who were threatening blunt chest injury.(5) With the near-routine use of CT treated at Al Rahba Hospital, Abu Dhabi, during a four-year for imaging in patients with multiple trauma, the diagnosis of period from October 2010 to October 2014 were retrospectively pneumothorax has increased.(1) This is particularly so for occult studied. Al Rahba Hospital is a community-based hospital, with pneumothorax, which is not detected on initial chest radiography. a capacity of 190 beds, located on the main highway connecting However, the need for chest tube insertion, which is an invasive Abu Dhabi and Dubai cities. About 700 patients with multiple procedure, for the management of small pneumothorax remains trauma are admitted to the hospital annually. controversial, especially for patients with occult pneumothorax.(6) Variables studied included demography, mechanism of injury, According to Advanced Trauma Life Support (ATLS) endotracheal intubation and mechanical ventilation, the need for guidelines, “Any traumatic pneumothorax is best treated with chest tube insertion, Injury Severity Score (ISS), Glasgow Coma a chest tube. Neither general anaesthesia nor positive-pressure Scale (GCS) score, Revised Trauma Score, hospital length of stay 1Department of Surgery, Al Rahba Hospital, Abu Dhabi, 2Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, 3Department of Radiology, 4Trauma Registry Program, Al Rahba Hospital, Abu Dhabi, United Arab Emirates Correspondence: Dr Ashraf F Hefny, Assistant Professor, Trauma Group, Department of Surgery, College of Medicine and Health Sciences, UAE University, PO Box 18532 Main Building of Post Office, Al-Ain, United Arab Emirates. [email protected] 150 Original Article and mortality. For patients who needed chest drainage, a chest 74 patients with pneumothorax on CT tube of size 28–32 French was usually inserted using the open technique at the fifth intercostal space. Antibiotics were not routinely administered. Clinical examination CT was performed using a General Electric 64-slice LightSpeed Volume (GE 64-slice LightSpeed VCT; General Electric, Boston, MA, USA). All patients underwent scanning of the entire thorax as Yes No Chest tube part of trauma CT. Images were analysed in the lung, mediastinal and bone windows at 2.5-mm thick axial cuts. CT images with 2 72 pneumothorax were further analysed in the coronal and sagittal planes. The images were reviewed to determine the size of Yes No Chest pneumothorax. The volume of pneumothorax was calculated in radiography millilitres (mL) using the manual segmentation method (software 40 32 available in the CT machine). Radiological images (including chest radiographs and CT images) were independently reviewed by two Yes No Chest radiologists. Patients with bilateral pneumothorax were analysed tube as one patient with two hemithoraces positive for pneumothorax. 7 33 The volume of pneumothorax in patients having bilateral pneumothorax was calculated by adding up the pneumothorax volumes in the two hemithoraces. The number of trauma patients who were treated in the Chest CT Chest CT emergency department and the number of trauma patients admitted were retrieved from the hospital’s trauma registry. The Al Rahba Hospital Research Ethics Committee approved the research Yes No 27 Yes Chest No Chest project (ARH/REC-040). tube tube Non-parametric methods were used to compare the two independent groups due to the small number of patients 13 20 12 20 recruited in the study.(8) Fisher’s exact test was used to compare Fig. 1 Management algorithm of patients with blunt trauma (n = 74) for categorical variables, while Mann-Whitney U test was used to whom pneumothorax was detected on computed tomography (CT). compare continuous or ordinal variables. Univariate analysis was used to compare patients with and without chest tube insertion Table I. Radiological findings of patients with and without chest subsequent to CT. Factors with p < 0.1 were then entered into a tube insertion after undergoing chest radiography following clinical examination. backward stepwise likelihood regression model. A p ≤ 0.05 in the model was considered statistically significant. Data was analysed Finding No. (%) p‑value* with IBM SPSS Statistics version 20 (IBM Corp, Armonk, NY, USA). Chest tube No chest tube insertion insertion (n = 20) (n = 20) RESULTS Normal 2 (10.0) 7 (35.0) 0.13 During the study period, 25,628 trauma patients were treated in Pneumothorax 9 (45.0) 1 (5.0) 0.008 the emergency department, among whom 2,860 (11.2%) patients Haemothorax 3 (15.0) 4 (20.0) 0.99 were admitted to the hospital. Fractured ribs 12 (60.0) 9 (45.0) 0.53 Chest CT was performed for 703 patients with blunt trauma. Lung contusion 7 (35.0) 6 (30.0) 0.99 Among these, pneumothorax was detected in 74 (10.5%) patients Subcutaneous 5 (25.0) 2 (10.0) 0.41 and all of them were admitted to the hospital. Of these 74 patients, emphysema 15 (20.3%) had bilateral pneumothorax and 63 (85.1%) were men. Patients could have more than one finding on chest radiography. *p-values were The median age of the patients was 30 (range 11–74) years. Median calculated using Fisher’s exact test. ISS and GCS scores were 18 (range 8–45) and 15 (range 3–15), respectively. The most common mechanisms of injury were road on chest radiography and one patient, who was mechanically traffic collision (n = 63, 85.1%) and fall from height (n = 7, 9.5%). ventilated and had rib fractures on chest radiography, had the Among the 74 patients, chest radiography was performed chest tube inserted prophylactically. prior to CT for 40 (54.1%) patients (Fig. 1). Overall, 9 (12.2%) Table I compares the radiological findings of chest radiography patients needed chest tube insertion before CT. For two patients that was performed following the initial clinical examination with obvious tension pneumothorax on clinical examination, the between patients with (n = 20) and without (n = 20) chest tube chest tube was inserted prior to chest radiography. For another insertion. In the former group, chest tube
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